Central retinal thickness fluctuations in patients treated with anti-VEGF for neovascular age related macular degeneration.

PURPOSE: This is a retrospective, single-center, non randomized interventional real life study, investigating the correlation between variability of central retinal thickness (CRT) and functional outcomes during 2 years of anti-VEGF therapy in patients treated for neovascular age related macular degeneration (nAMD). BACKGROUND: CRT fluctuations can depend on various factors such as the correct timing of injections, the therapeutic algorithm, and the number of injections (NI) performed; it is important to understand if CRT fluctuations are responsible for worse visual outcomes and consequently to identify the correct ways to avoid or reduce them. METHODS: Forty-one patients were treated for nAMD with aflibercept: 0.5 mg intravitreal aflibercept was administered every 4 weeks during the first 3 months, then bimonthly over the first year, and after the first year adopting a PRN regimen. Standard deviation of CRT (CRT/SD), BCVA, and NI were recorded. Correlation studies were performed by Pearson's test, Ancova, and Principal Component Analysis. RESULTS: A negative correlation was found between CRT/SD and final BCVA. In patients who lost more than 15 letters, CRT/SD mean was significantly higher in comparison with patients who lost less than 15 letters. Patients with final BCVA >65 letters showed lower CRT/SD values compared to patients with final BCVA ⩽65 letters. Multivariate analysis confirmed that in patients with higher baseline BCVA, improvement of BCVA was correlated to NI, and lower values of CRT fluctuations were observed. CONCLUSIONS: CRT fluctuations, even after an appropriate NI given per year, significantly influence BCVA; a proactive treatment algorithm appears crucial when treating patients with nAMD.

Choroidal neovascular membrane following hormonal stimulation for in vitro fertilization.

PURPOSE: To report the onset of choroidal neovascularization (CNV) following hormonal stimulation for in vitro fertilization (IVF) in a healthy young woman. METHODS: A 31-year-old woman presented with visual impairment following hormonal stimulation for IVF. Clinical history was collected and best-corrected visual acuity (BCVA), complete eye examination, optical coherence tomography (OCT), fluorescein angiography (FA), and indocyanine green angiography were -performed. RESULTS: Clinical history was negative with the exception of the use of medications for IVF in the previous weeks. Ocular examination revealed the presence of a CNV in the right eye, confirmed by OCT and FA, with a BCVA of 0.7 decimal units. Possible ocular and systemic diseases associated with CNV development were investigated and excluded. Treatment with 3 monthly intravitreal injections of anti-vascular endothelial growth factor (VEGF) was effective in reducing CNV size and restoring visual acuity. CONCLUSIONS: This is the first report describing the development of CNV following hormonal stimulation for IVF. The development of CNV may be associated with changes of sex hormones, cytokines, and angiogenic factor levels, including VEGF, induced by hormonal stimulation.

Early onset keratectasia after photorefractive keratectomy in a case showing Vertical D topographic pattern.

PURPOSE: We describe a case of early onset keratectasia after photorefractive keratectomy (PRK) in a patient with Vertical D topographic pattern in one eye and suspected keratoconus in the other eye. METHODS: A 31-year-old woman underwent bilateral PRK: attempted correction was -8.00-2.00 × 30° in her right eye (RE) and -4.50-1.50 × 150° tabo in her left eye (LE). Preoperative corneal thickness was 512 µm in the RE and 520 µm in the LE. Preoperative topography showed an asymmetric bow-tie pattern and skewed axis in RE and a Vertical D pattern in LE. Intended maximum ablation was 91 µm in RE and 66 µm in LE. RESULTS: Three months postoperatively the patient showed early topographic signs of bilateral keratectasia, evolved to manifest keratectasia after six years. CONCLUSIONS: Although rare after PRK, keratectasia may occur even following moderate (66 µm) surface ablation in eyes with Vertical D topographic pattern in one eye and controlateral suspected keratoconus.

Pain during second eye cataract surgery under topical anesthesia: an intraindividual study.

BACKGROUND: Aim of the study was to investigate: 1) if second eye cataract surgery under topical anesthesia is more painful than surgery on the first eye, 2) if pain experienced during the procedure on the first eye may predict the pain of the second procedure, and 3) if patients' cooperation is different between the first and the second eye procedure. METHODS: Seventy-three consecutive patients undergoing bilateral non-simultaneous cataract surgery were prospectively included in the study. Surgical technique was sutureless clear corneal phacoemulsification under topical anesthesia. Immediately after surgery every patient graded the pain experienced using a visual analogue scale (VAS) from 0 (no pain) to 10 (unbearable pain). At the end of each procedure the surgeon graded patients' cooperation using a 4-point scale. RESULTS: Mean VAS score was 2.35 (SD 2.63) for the first eye and 2.89 (SD 2.93) for the second eye. Such a difference was not statistically significant (p = 0.1777, Wilcoxon test). The correlation between the VAS score of the first and that of the second procedure was statistically significant (r = 0.5514, p < 0.0001, Spearman rank correlation). Patients' cooperation was 2.64 (SD 0.63) during the first procedure and 2.52 (SD 0.79) during the second procedure; this difference was not statistically significant (p = 0.1769, Wilcoxon matched-pairs signed-ranks test). CONCLUSIONS: After uneventful cataract surgery under topical anesthesia, pain experienced and cooperation did not differ between first and second eye procedures. A correlation was found between pain scores of the first and the second eye procedures.

Efficacy of topical plus intracameral anesthesia for cataract surgery in high myopia: randomized controlled trial.

PURPOSE: To assess the efficacy of intracameral lidocaine supplementation of topical anesthesia during cataract surgery in eyes with high myopia. SETTING: Department of Ophthalmology, Ospedale San Pietro-Fatebenefratelli, Rome, Italy. METHODS: This prospective double-blind study comprised 120 highly myopic eyes with an axial length (AL) greater than 26.0 mm scheduled for routine cataract surgery. Cases were divided into 2 groups of 60 eyes each. One group received a placebo of balanced salt solution (BSS) (control group) and the other group, a supplement of 0.1 mL preservative-free lidocaine hydrochloride 1% injected in the capsular bag during hydrodissection (lidocaine group). Intraoperative pain was assessed by recording spontaneous patient reports of sensation of pain or ocular discomfort during 3 surgical stages: phaco tip insertion, irrigation/aspiration (I/A) system insertion for cortical aspiration, I/A system insertion for ophthalmic viscosurgical device removal after intraocular lens implantation. Postoperative pain was assessed on a visual analog scale (range 0 to 10). Data were compared by chi-square and Mann-Whitney U tests. RESULTS: The overall mean AL was 28.58 mm (28.57 mm control group; 28.50 mm lidocaine group). Fewer patients in the lidocaine group reported intraoperative pain, ocular discomfort, or tissue manipulation (odds ratio=0.36; 95% confidence interval, 0.16-0.80; P= .019). The mean postoperative pain score was 1.88+/-2.17 (SD) in the control group and 1.36+/-2.02 in the lidocaine group; the difference was not statistically significant (P= .21). CONCLUSION: Intracameral lidocaine supplementation for cataract surgery may improve intraoperative comfort under topical anesthesia in highly myopic eyes.

Lidocaine 2% gel versus lidocaine 4% unpreserved drops for topical anesthesia in cataract surgery: a randomized controlled trial.

OBJECTIVE: To compare intracameral levels and clinical efficacy of lidocaine 2% gel with lidocaine 4% unpreserved drops. DESIGN: Double-blind, randomized, one-surgeon, controlled trial. PARTICIPANTS: One hundred seven consecutive cataract cases eligible for topical anesthesia. INTERVENTION: Patients were randomly assigned to receive 20 mg of lidocaine either as lidocaine 2% gel (1 ml) or as lidocaine 4% unpreserved eyedrops (0.5 ml) before clear corneal phacoemulsification. MAIN OUTCOME MEASURES: Aqueous samples were taken to measure lidocaine intraocular levels. Intraoperative pain was quantified a few minutes after surgery using a 0 to 10 visual analog scale. SECONDARY OUTCOME MEASURES: Patients were asked to grade the degree to which they were bothered by tissue manipulation. The surgeon graded patients' cooperation. The anesthesiologist recorded any increase in pulse or blood pressure and the need for supplemental topical anesthesia or intravenous sedation. Duration of surgery and intraoperative complications were also recorded. RESULTS: In the gel group intracameral lidocaine levels were significantly higher (P < 0.001) and patient-reported intraoperative pain scores were significantly lower (P = 0.026). Patients in the gel group were bothered by tissue manipulation to a lesser extent (P = 0.028), and their cooperation was better (P = 0.002). Increases in blood pressure were more frequent in the eyedrops group. Supplemental anesthesia was required in two cases (3.70%) in the gel group versus eight cases in the eyedrops group (15.09%). No correlation between intracameral lidocaine levels and intraoperative pain scores was found (r = -0.026, P = 0.789). CONCLUSIONS: If administered by means of gel, the same amount of lidocaine gives significantly higher intracameral levels of lidocaine, better analgesia, better patient cooperation, and less need for intraoperative supplemental anesthesia. Lower pain scores do not correlate with intracameral lidocaine levels.